Bernardino de Concilio

Neovaginal prolapse in male-to-female transsexuals: an 18-year-long experience.

Neovaginal prolapse is a rare and distressing complication after male-to-female sexual reassignment surgery. We retrospectively analysed the prevalence of partial and total neo-vaginal prolapses after sexual reassignment surgery in our institute. During the years, two different techniques have been adopted with the aim of fixing the neovaginal cylinder. In the first, two absorbable sutures are placed at the top of the penoscrotal cylinder and fixed to the Denonvilliers fascia. In the second, two additional sutures are added from the posterior/midpoint of the flap to the prerectal fascia. We enrolled 282 consecutive transsexual patients. 65 (23.04%) out of the 282 were treated with the first technique and the following 217 (76.96%) with the last technique. In the first technique, 1 case (1.53%) of total prolapse and 7 cases (10.76%) of partial prolapse were observed, while in the other 217 patients treated with the second technique only 9 cases of partial prolapse were observed (4.14%) and no cases of total prolapse. All prolapses occurred within 6 months from the procedure. In our experience, the use of 4 stitches and a more proximal positioning of the sutures to fix the penoscrotal apex with the Denonvilliers fascia guarantees a lower risk of prolapse.

Varicocele treatment: A 2-centers comparison between non microsurgical open correction, laparoscopic approach and retrograde percutaneous sclerotization on 463 cases

OBJECTIVES To determine whether there are differences in sperm parameters improvement after different varicocele correction techniques. To determine the role of age in sperm parameters improvement. METHODS 2 different European centers collected pre- and postoperative sperm parameters of patients undergoing varicocele correction. Among 463 evaluated patients, 367 were included. Patients were divided in procedure-related and age-related groups. Ivanissevich inguinal open surgical procedure (OS), lymphatic-sparing laparoscopic approach (LSL) and retrograde percutaneous transfemoral sclerotization (RPS) were performed. As outcome measurements sperm count (millions/mL, SC) and percentage of mobile sperms were analyzed. Univariate and multivariate regression between the defined groups; bivariate regression analysis between age and sperm count and motility. RESULTS Number of patients: OS 78; LSL 85; RPS 204. Mean age 30.2 (SD 6.83); postoperative SC increased from 18.2 to 30.1 (CI 95% 27.3-32.9; p < 0,001); motility from 25.6 to 32.56% (30.9-34.2; p < 0.001). OS: SC varied from 16.9 to 18.2 (p < 0.001); sperm motility from 29% to 33% (p < 0.001). LSL: SC from 15.5 to 17.2 (p < 0.001); motility from 27 to 31% (p < 0.001). RPS: SC from 18.9 to 36.2 (p < 0.001); motility from 24% to 32% (p < 0.001). Univariate and multivariate analysis confirmed the significant difference of SC variation in RPS, compared to the other groups (p < 0.001). No significance between LSL and OS (p = 0.826). No significant differences regarding motility (p = 0.8). CONCLUSIONS Varicocele correction is confirmed useful in improving sperm parameters; sclerotization technique leads to a better sperm improvement compared to other studied procedures; improvement in seminal parameters is not affected by age of the patients treated.

MP49-02 PERIOPERATIVE MORBIDITY OF CLAMP VS OFF-CLAMP ROBOTIC PARTIAL NEPHRECTOMY: PRELIMINARY RESULTS FROM A MULTICENTRE RANDOMIZED CLINICAL TRIAL (THE CLOCK STUDY)

INTRODUCTION AND OBJECTIVES: To assess the significance of mannitol used as renal protective agent during nephronsparing surgery (NSS) on renal functional outcomes after NSS. METHODS: A prospective, randomized, placebo-controlled, double-blind, phase 3 trial (ClinicalTrials.gov identifier NCT01606787) designed to detect a 5% difference between treatment arms with a power of 90%. Patients were randomized 1:1 to receive mannitol (12.5 g) or normal saline solution placebo intravenously within 30 min prior to renal vascular clamping. Eligibility criteria included age >18 yr, renal artery clamping during NSS, and preoperative estimated glomerular filtration rate (eGFR) >45 mL/min/1.73m. Intraoperatively, a standardized fluid management algorithm was used to maintain hemodynamic stability and urine output 0.5 mL/kg/h. Postoperatively, eGFR was obtained at 6 wk and 6 mo. A renal scan was obtained pre operatively and at the 6-mo endpoint. An ANCOVA model was used to assess the differences in eGFR at 6 wk and 6 mo, and in renal scan at 6 mo after NSS. Differences in grade 3-5 complications were assessed using Fisher0s exact test. At the interim analysis on the first 88 patients, the O0Brien-Fleming stopping boundaries requiring a significance level of 0.0031 were not met (p 1⁄4 0.6). RESULTS: A total of 105 patients per treatment arm were enrolled. After excluding 11 patients (7 in the placebo and 4 in the mannitol arm) who did not undergo NSS; 2 patients (1 in each arm) converted to radical nephrectomy, and 1 patient from the mannitol arm who never received the study drug, 98 and 101 patients in the placebo and mannitol arms, respectively, were evaluated. Median age was 56 yr (interquartile range [IQR] 48, 63) and 60 yr (IQR 50, 66) in the placebo and mannitol arm, respectively. Comparing placebo to the mannitol arm, the adjusted difference of 0.2 eGFR units at 6 mo after NSS was not significant (95% confidence interval [CI] -3.1, 3.5; p1⁄4 0.9). The adjusted difference of -2.6 eGFR units at 6 wk after NSS was not significant (95% CI -5.8, 0.7; p 1⁄4 0.12). No significant differences were detected between treatment arms in median split function on 6-mo renal scan (difference -1.7; 95% CI -3.8, 0.4; p 1⁄4 0.11), or in grade 3-5 complication rates within 90 days of NSS (difference 3.2%; 95% CI -4.1%, 11%; p 1⁄4 0.4). CONCLUSIONS: This randomized prospective trial provides evidence against the use of mannitol as renal protective agent during NSS since no clinical or statistically significant advantage to the use of intravenous mannitol in patients undergoing NSS was found.

The Infertile Male-1: Clinical Features

Male infertility affects 10% of couples and is treatable in many cases. The evaluation of infertility is initiated typically after 1 year of failure to conceive. Clinical evaluation of the infertile man requires a complete medical history, physical examination, and laboratory studies in order to identify and treat correctable causes of subfertility and recognize those who are candidates for assisted reproductive technologies, those who are sterile and should consider adoption or artificial insemination using donor sperm, and those who should undergo genetic screening. Although pregnancies can be achieved without any evaluation other than a semen analysis, this test alone is insufficient to adequately evaluate the male patient. Treatment of correctable male-factor pathology is cost effective, does not increase the risk of multiple births, and can spare the woman invasive procedures and potential complications associated with assisted reproductive technologies.

A Novel Technique for Robotic Simple Prostatectomy: An Evolution of Retzius-sparing Technique

OBJECTIVE To present a novel surgical concept by using the trans-Douglas approach to perform a robotic-assisted simple prostatectomy (RASP) for high-volume benign prostate hyperplasia. This transposition from oncological surgery enables performance of a better bladder neck sparing adenomectomy with good functional results. MATERIALS AND METHODS The index patient is a 67-year-old man with a history of severe urinary flow outlet obstruction. Combination medical therapy is not effective. Transrectal ultrasound scan detected a 130-cm3 enlarged prostate with middle lobe. The International Prostate Symptoms Score (IPSS) was 30. The patient was scheduled for a RASP with a trans-Douglas approach to preserve the bladder neck. The patient was put in 30° Trendelenburg position. Six ports were placed across the lower abdomen: four 8-mm robotic trocars and 2 assistant trocars (12 and 5 mm). The parietal peritoneum was incised at the anterior surface of the Douglas space, according to the access to the prostate described by Bocciardi. The Denonvillier fascia was opened, seminal vesicles were exposed, and above the vesicles, the prostatic capsule was incised. The adenoma, together with the middle lobe, was split by the capsule from the base to the verumontanum. The bladder neck was advanced and remodeled to the distal urethral mucosa and then closed to the prostatic capsule by a double-layer suture. The peritoneal breach was closed. RESULTS The operation time was 120 minutes. Blood loss was 80 cc. There was no perioperative or postoperative complication. The catheter was removed after 4 days. Uroflowmetry showed a peak flow of 30 mL/s. Pathologic examination was negative for tumor. After 60 days, the IPSS score was 8. CONCLUSION Trans-Douglas-RASP is a safe and effective minimally invasive treatment for benign prostate hyperplasia. It is a novel technique to perform bladder neck sparing prostatic adenomectomy and could be 1 more field of application of robotic technology.

Robot-assisted Partial Adrenalectomy for the Treatment of Conn's Syndrome: Surgical Technique, and Perioperative and Functional Outcomes

BACKGROUND In the era of minimally invasive surgery, partial adrenalectomy has certainly been underused. We aimed to report surgical technique and perioperative, pathologic, and early functional outcomes of a two-center robot-assisted partial adrenalectomy (RAPA) series. OBJECTIVE To detail surgical technique of RAPA for unilateral aldosterone-producing adenoma (UAPA), and to report perioperative and 1-yr functional outcomes. DESIGN, SETTING, AND PARTICIPANTS Data of 10 consecutive patients who underwent RAPA for UAPA at two centers from June 2014 to April 2017 were prospectively collected and reported. SURGICAL PROCEDURE RAPA was performed using a standardized technique with the da Vinci Si in a three-arm configuration. MEASUREMENTS Baseline and perioperative data were reported. One-year functional outcomes were assessed according to primary aldosteronism surgery outcome guidelines. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS All cases were completed robotically. Median nodule size was 18mm (interquartile range [IQR] 16-20). Intraoperative blood loss was negligible. A single (10%) postoperative Clavien grade 2 complication occurred. Median hospital stay was 3 d (IQR 2-3). Patients became normotensive immediately after surgery (median pre- and postoperative blood pressure: 150/90 and 120/70mmHg, respectively). At both 3-mo and 1-yr functional evaluation, all patients achieved biochemical success (aldosterone level, plasmatic renin activity, and aldosterone-renin ratio within normal range). Complete clinical success was achieved in nine patients, but one required low-dose amlodipine at 6-mo evaluation. At a median follow-up of 30.5 mo (IQR 19-42), neither symptoms nor imaging recurrence was observed. CONCLUSIONS We demonstrated feasibility and safety of RAPA for UAPA; this technique had very low risk of complications and excellent functional results. Increased availability of robotic platform and increasing robotic skills among urologists make RAPA a treatment option with potential for widespread use in urologic community. PATIENT SUMMARY Robot-assisted partial adrenalectomy is a safe, feasible, and minimally invasive surgical approach. Promising perioperative and functional outcomes suggest an increasing adoption of this technique in the near future.

V6-05 ROBOTIC PARTIAL ADRENALECTOMY FOR SYMPTOMATIC ALDOSTERONE-SECRETING ADENOMAS: TECHNIQUE AND OUTCOMES

INTRODUCTION AND OBJECTIVES: Early allograft dysfunction (EAD) can be caused by a number of technical factors including vascular complications such as thrombosis and kinking. Retroperitoneal compartment syndrome (RACS) is an under-recognized vascular cause of EAD with potentially devastating consequences, and may even result in a lost graft. The graft can be salvaged with early recognition and intervention through a mesh hood fascial closure (MHFC) technique. METHODS: Here we describe, in video, a 23-years-old male recipient diagnosed with renal failure secondary to chronic reflux. He has a 6months history of peritoneal dialysis and is currently on hemodialysis. The patient received an anonymous living-donor right kidney from our paired exchange program. His BMI is 22. The graft had a single renal artery and single renal vein. A standard anastomosis was performed and subsequent urine output was brisk. The fascia was closed without tension. However, urine production ceased after the fascia was fully closed. A case of RACS was suspected and intraoperative Doppler ultrasound showed no blood flow in the graft. Immediately re-exploration revealed the graft to be abnormal in color and turgor. RESULTS: These abnormalities resolved after pressure was relieved. The kidney was then placed in the optimal position within the iliac fossa and a large ellipsoid piece of polypropylene mesh was draped loosely and without tension over the graft. The mesh was attached to the posterior fascial edges using interrupted #1 polypropylene sutures. Skin closure then was completed over a closed suction drain placed in the retroperitoneal space lateral to the kidney. Doppler ultrasound after skin closure showed good flow and the postoperative course was unremarkable. CONCLUSIONS: RACS could be associated with small android pelvis and lack of compliance in the retroperitoneal cavity secondary to peritoneal dialysis. Suspected RACS require prompt intervention to prevent irreversible graft dysfunction. We have shown that MHFC is an effective and safe method to treat EAD secondary to RACS.

Robotic-assisted partial nephrectomy: experience on 60 cases.

Introduction Laparoscopic partial nephrectomy is still one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumor. Robotic-assisted partial nephrectomy (RALPN) adds the advantages offered by the “Da Vinci system” to laparoscopy, such as the 3-D vision, and the better degree of freedom of surgical instruments. Objective The objective of this study is to report our experience with RALPN. Methods From August 2009 to October 2012, 60 patients underwent RALPN for kidney cancer. The average age of the patients (35 female, 25 male) was 63 (range 48–80) years. Average BMI was 25 (range 21.8–29.7) kg/m2. Average tumor size was 3.2 cm (range 2-6.7 cm). All the procedures were performed by a transperitoneal approach, liar clamping was used in all cases: in 47 patients by one intracorporeal tourniquet for the artery and one for the vein; in three cases, ilar clamping was “en block” by Satinsky. Results Mean operative time was 167.2 min (140–250) with a WIT of 23.8 min (15–28). The mean estimated blood loss was 260 mL (50–300). In one case, nephrectomy was necessary because the tumor involved the renal pedicle. One patient had pulmonary embolism and one urinary leakage conservatively managed. Pathologic examination revealed clear cell renal cell carcinoma in 58 patients, oncocytoma in one patient, and angiomyolipoma in one patient. All resection margins were free from tumor. Conclusions Partial nephrectomy, facilitated by robotic technology, is more and more frequently performed as a safe and effective minimally invasive procedure.

Surgery in Complications: Ileal Vaginoplasty

The surgical management of neovaginal stenosis in a transsexual patient is a complex problem and constitutes a significant technical challenge.

The Infertile Male-4: Management of Obstructive Azoospermia

Azoospermia is the total absence of spermatozoa in the ejaculate. It is found in 10–15% of male infertility cases and is caused by a testicular insufficiency in the majority of patients. Obstructive azoospermia is less frequent and arises in 15–20% of men with azoospermia. Most causes of male infertility are treatable, and many treatments restore the ability to father a children naturally. In case of vasal or epididymal obstruction, microsurgical reconstruction of the seminal pathways, if possible, remains the safest and most cost-effective treatment option for these patients, allowing natural conception in many cases. Not all men with obstructive azoospermia are treatable by microsurgical reconstruction. In such situations, various sperm-retrieval techniques can be employed to take sperm for use with in vitro fertilization (IVF) via intracytoplasmic sperm injection (ICSI).